Intubation of COVID-19 Patients: Does Timing Change Outcomes?

Those of us who take care of COVID patients in the ICU wonder what is the best for our patients regarding intubation. We learned early in the course of the pandemic that proceeding with early intubation was not beneficial to our patients. You all have also see the patient who has a PaO2 of 55 on high-flow nasal cannula at 60L and 100% FiO2 get intubated and next thing you know, they are on 18 of PEEP with 100% FiO2 and their sats are in the toilet. Some of these patients really do not like the ventilator.

I’m afraid that history may not be kind to us in how we took care of these patients. I can’t admit to knowing what the right thing to do is and it really burdens me. By no means am I going to be covering extremely robust data on this. It does not exist. Thankfully, the team over at Emory took a look at this data.

How do we decide when to proceed with intubation in COVID patients?

No need to reinvent the wheel here. I use a number of parameters to help me decide when to pull the trigger with intubation. To put it lightly, many times it’s “the look” I get from the respiratory therapists. The eyeball test holds some good weight. The honest question we’ve all asked ourselves is “are we waiting too long?”. It’s something that honestly burdens me as well as the team. I have discussed the ROX score before as a method for determining whether a patient should be intubated. It’s something that honestly burdens me as well as the team.

What did the authors do?

They performed a retrospective look of COVID patients who were either on HFNC or the team proceeded with intubation. People wondered about the aerosolization of COVID with HFNC but Emory had a policy stating that this is no big deal. They were against using NIV (what some of us call BiPAP). If you use NIV on these patients, you really have to be careful with your IPAP settings. You don’t want your patient taking these enormous tidal volumes causing trauma to the lungs.

In total, they reviewed 231 patients. 47.2% were on HFNC and 42% were intubated before even trying HFNC. The HFNC system saved 28% of patients from needing intubation.

What did the authors find?

The authors “found no association between time to intubation and either mortality, ventilator duration, or ICU length of stay, even after accounting for patient comorbidities, clinical presentation, and severity of illness. In addition, we found no association between the timing of intubation and subsequent oxygenation, as measured by initial P:F ratio, or static compliance.”

The authors concluded that, although this was a retrospective study, their “analysis provides reassurance that delays in intubation are not significantly associated with further lung injury in this vulnerable population of critically ill patients”. Using HFNC saved 28% of their patients from needing intubation and everything associated with it.

Cool, but how long did they delay? Some of us in the real world have had patients on HFNC for weeks. This information can be teased out from the fact that the median time to intubation (of those patients who ended up intubated) for those who lasted >24 hours on HFNC was 2.3 days with a range of 1.0-8.3 days. They don’t discuss how long that 28% of the patients who remained on HFNC and didn’t buy the ETT remained on HFNC. Or perhaps I missed it. This is a good time to remind you to read the article for yourself and not trust me. I could miss things. A hat tip to the authors!

Some interesting facts regarding the patients that underwent intubation for COVID

Some other interesting facts. Having a P:F ratio <100 carried a 43% mortality. The median duration of mechanical ventilation was 9.0 days. The median ICU length of stay was 12.8 days.

If you’re curious about the inflammatory markers, the CRP was 176mg/dL although I think that they really meant either mg/L or mcg/ml. I could be wrong. D-dimer was also elevated at 1.4mcg/mL. No specifications on anticoagulation in this paper. They didn’t discuss other treatments either.

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Hernandez-Romieu AC, Adelman MW, Hockstein MA, et al. Timing of Intubation and Mortality Among Critically Ill Coronavirus Disease 2019 Patients: A Single-Center Cohort Study [published online ahead of print, 2020 Aug 14]. Crit Care Med. 2020;10.1097/CCM.0000000000004600. doi:10.1097/CCM.0000000000004600
Link to Abstract

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